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C2Q Health Solutions · 3 weeks ago

CLAIMS AND CREDENTIALING ANALYST

NY Bronx / Olinville Avenue

Full-time

Onsite

Mid Level

$75K/yr - $85K/yr

3+ years exp

C2Q Health Solutions is seeking a Claims and Credentialing Analyst to join their team. The role involves analyzing and coordinating the activities of the Provider Data team, ensuring compliance with various guidelines, and managing the credentialing process efficiently.

Management Consulting

Responsibilities

Coordinate provider credentialing process to increase efficiency and ensure that credentialing deadlines are met

Research and solve credentialing/re-credentialing delays & issues with enrollment in a timely manner

Manage confidential information of internal staff (Physicians, Nurse Practitioners)

Ensure demographic updates are reviewed and verified for processing

Ensure the database is kept accurate and updated

Maintain necessary logs, lists, records, and current documentation required for physician/provider credentialing and re-credentialing to ensure requirements are met in a timely manner

Prepare documents for Credentialing Committee review

Outreach to provider for information verification and miscellaneous inquiries, i.e. provider portal access, nursing home documentation, medical records retrieval, etc

Perform in-depth provider claims analysis using multiple data sets, conduct root cause analysis, and drive process improvements to achieve measurable outcomes and operational efficiency

Collect and prepare data for state, federal, and internal inquiries, ensuring accuracy and compliance with regulatory requirements

Coordinate with Finance Department regarding check runs and provider payments, including handling refunds, overpayments, and underpayments

Review and investigate claims to be adjudicated by the Third-Party Administrator (TPA), applying contractual provisions in accordance with provider contracts and authorizations

Review monthly capitation payments in accordance with contractual obligations

Perform analysis on capitation payments to determine trends or discrepancies on the payments as well as determine improvements on the process

Prepare analysis on network provider performance through the development of monthly provider scorecard, working with other key stakeholders to ensure providers are meeting their contractual requirement and identify areas for improvement

Provide productivity and issues reports for Management

Remain current on policies affecting provider credentials and enrollment processes

Other duties as assigned

Qualification

Credentialing experienceData analysisHealthplan credentialingMicrosoft Office ProficientProblem solvingTime managementCommunication skillsOrganizational skills